1. What behaviour change is Smile Train addressing? Does it involve all types of behaviour change?

explain briefly

Smile Train India: A Social Marketer Targeting Cleft

Lip/Palate as a Socio-Medical IssueSivakumar Alur

Campaign Background

In India, an estimated 28,000-35,000 children are born with cleft lip or palate every year. Only about one-sixth of these children undergo corrective surgery by a trained surgeon (https://www.smiletrainindia.org/media/press/smile-train-completes16000-free-cleft- surgeries-orissa). Others endure cleft lip and palate, if they survive until adulthood, due to illiteracy and poverty. Vitamin deficiency, high exposure to tobacco and alcohol, viral infections, and specific medications during a mother's pregnancy raise cleft risk for the child.

Genetic causes like gene mutation and cleft incidence in the family could also be the reasons for cleft lip. An exact diagnosis of the cause of cleft is difficult.

Cleft lip and cleft palate are two different facial deformities that affect children for multiple reasons. While doctors can detect cleft lip during pregnancy using scans, cleft palate is difficult to detect. When doctors detect cleft lip, they advise parents to seek surgical correction within 6 months of childbirth. Poor reading of scans and untrained sonologists and doctors can miss cleft lip detection during pregnancy.

In many cases, parents of cleft children do not seek surgery due to several reasons. Parents lack access to health care facilities and surgeons that require specialized training for surgery and post-operative care. Some parents are superstitious (Naram et al., 2013). They consider cleft not as a treatable medical condition but asGod's curse(http://www.asianage.com/india/over-10-lakh-kids-indialive-cleft-lips-055). A few local cultures blame the mother for various unscientific reasons like (a) using a knife during aneclipse or (b) having committed adultery, for the child's cleftlip. Some families cite previous instances of miscarriage or cleft lip as a condition in the family as the reason. Poor parents cannot afford tertiary health care where a specialist team of doctors and paramedical staff need to work. In very complicated cases, multiple surgeries over time and sensitive post- operative care entail additional expenses (https://yourstory.com/2017/03/smile-train- indiacleft-surgeries/). Parents due to fear and religious reasons do not undertake corrective surgery for cleft treatment.

Cleft lip results in the baby or an adult to suffer several difficulties. A disfigured face leading to social ostracism is a common problem. Schoolmates and various society members ridicule and denigrate cleft patients due to disfigured faces. Cleft also results in life threatening conditions like difficulty in breathing, drinking milk or liquids in children, and intake of food. This can lead to inadequate nutrition and stunted growth. Many cleft patients end up with a sonorous voice as they grow up due to the gap in the lip and palate (http://www.thehindu.com/features/magazine/ Cleft-no-more/article12086004.ece). In addition, cleft creates ear and nose infection, as the ear, nose, and throat are related organs. Infection spreads from one of these organs to another easily. Smile Train India is the Indian arm of the US-based Smile Train that works to provide free cleft surgeries in India. India is one of the major operating countries of this social marketing organization. The key focus of this organization has been to increase awareness about cleft among all stakeholders and help poor families with cleft-afflicted children with funding to undertake surgery for cleft correction. Smile Train USA started in 1999 and the activities in India started in 2000.

Social marketers usually follow a phased implementation of their programs, namely policy advocacy followed by engaging community leaders, and then targeting the primary audience. This would mean the strategy of regulate, educate, and facilitate. However, Smile Train follows the strategy of educating the community on cleft and facilitating cleft surgeries simultaneously.

SWOT Analysis

Strength

The biggest strengths of Smile Train are the various stakeholders (namely partner hospitals and doctors/clinics [http://zeenews.india.com/sports/tennis/wimbledon2382013/smiling- pinki-flips-coin-at-wimbledon_764772.html]), the target population (namely parents of cleft- afflicted children), and adults and donors who contribute to this cause. The dedicated staffs and their smaller number compared to similar social marketing organizations is another key strength. The partnership and networking model facilitates working with a small staff. Partner hospitals not only facilitate cleft surgeries but undertake comprehensive cleft care. These hospitals offer either cleft surgeries and/or comprehensive cleft care free due to their service for the cause or because Smile Train covers their costs due to their partnership. The parents of affected children and cleft-affected adults after treatment turn into voluntary ambassadors for the cause. Being an international charity helps Smile Train benefit from its global network and its US-based parent organization.

A key strength of Smile Train is that it operates as a local organization. It partners local hospitals and clinics and its spare capacity for cleft surgeries and cleft care. Such partnershipshelp poor cleft patients too, as they facilitate easy access to affordable care. Smile Train'ssustainable financial model is another major strength (http://www.afaqs.com/news/story/46992_Cleft-patient-Jyothi-smiles-for-the-firsttime-with- Himalaya-Lip-Care). It follows a combination of pro-bono surgeons and other healthcare staff, corporate and individual donors, and funding through government schemes to sustain its organization.

Smile Train India employs information technology and Internet efficiently for its activities and processes. It has an updated Web site that provides useful information for various stakeholders. Cleft surgeons are their key stakeholders. A free web-based virtual surgical simulator helps cleft surgeons to practice cleft surgery. Cleft specialists among researchershave access to Smile Train's largest web-based global cleft database. In addition, its specialist review panel ensures that the cleft surgery adheres to quality parameters.

Smile Train started as US-based charity in 1999. Its vast global experience has added to its learning and reputation across different communities.

Weaknesses

The greatest weakness of Smile Train is its operational model. Its operational model involves activities that encompass awareness building to comprehensive cleft care. However, it focuses mainly on acting as a facilitator between donors and corrective surgery patients. If the network of donors, hospitals, and doctors shift from Smile Train to competitors, it can hardly stop this shift. Smile Train focuses on cleft corrective surgeries. This entails work on cleft after it has set in as a medical condition in an individual. However, prevention is another way of working on this condition. Thus, while the focus is on cure, lesser focus on prevention is a weakness.

Opportunity

Smile Train operates globally, especially in populous countries like India where cleft prevalence is high. However, tertiary health care required for cleft surgeries are mostly available in urban areas. As rural patients have lesser access to tertiary care, expanding cleftcare services to remote rural areas is an opportunity. India's rural poverty and illiteracy aregreater than urban areas. Opportunity exists to, therefore, spread awareness and fundsurgeries in rural areas to advance Smile Train's mission.

Another opportunity available is to work with different social organizations. This would help Smile Train to serve several patients and foster behavioural change. Smile Train can work with governments to bring in legislation to facilitate better lives for cleft-affected. This effort can include cleft specialist certification for doctors and other paramedical staff and sensitization programs for employers about cleft as a medical condition.

Threats

Health insurance is under penetrated in India. Currently, Smile Train India connects funding from donors to hospitals that perform cleft corrective surgery on poor patients. This model works in India as most health care costs are borne as direct private payment. However, increased coverage of employer or government provided health insurance could make cleft surgery funding slowly redundant. In addition, better access to low-cost tertiary government health care can reduce private health care dependence.

Greater health literacy can help reduce the need for cleft surgeries. More information and awareness on causes of cleft among prospective mothers act to prevent clefts among newborns significantly. Greater monitoring of the expecting mothers during pregnancy can reduce cleft childbirths. This monitoring could involve providing adequate nutrition and vitamins. It could also entail advising pregnant mothers to avoid tobacco and alcohol as it would increase the risk of a cleft child being born.

Target Audience

The target audience is the cleft patients and their parents who need the medical and financial help. Cleft patients are mainly children who are not earning members. They need to get help from their parents. However, these parents are usually from a poor economic background.They need education about cleft corrective surgery and money to perform their children'ssurgery. Donors are another target audience who need to be convinced about donating for cleft corrective surgery compared to other social causes.

The secondary target audience also includes specialist doctors (e.g., cleft surgeon), paramedical staff (e.g., nurses), hospitals, schools, and the community that need to be aware and act in reducing cleft incidence.

Campaign Initiatives and Objectives

Smile Train's overall campaign objective is to ensure comprehensive cleft care for childrenof economically weak parents. The main campaign initiatives are to raise the awareness among children, adults, and parents that (a) cleft is a curable condition; (b) cleft care requires a multi-pronged approach involving the medical and social intervention; and (c)

economically poor parents can seek Smile Train's help in cleft corrective surgery. The otherimportant objectives are (a) raising public and doctors' awareness about economic and social issues surrounding cleft and (b) increasing donors' awareness about donating for cleft careand its positive social implications. Smile Train India's key objectives are to provide freecorrective cleft surgery to each one of the estimated 35,000 newborns with cleft, training Indian doctors to conduct cleft surgeries, and providing Indian hospital funding for the procedures.

Barriers, Benefits, and Competition

The key barriers to cleft prevention and treatment are (a) lack of awareness, (b) financial- and access-related difficulties in taking steps to prevent or treat, (c) superstitious beliefs that onecannot prevent cleft and it is God's curse or one should not change a cleft lip or palate, (d) paucity of time to go through comprehensive cleft post-operative care, and (e) misinformation that cleft is not treatable or may take too much time, effort, and money.

The key benefits for the target audience in cleft are (a) better quality of life as a whole, (b) reduction in ear, nose, and throat infection, (c) better physical growth due to better nutrition and food intake, (d) greater societal acceptance due to the change in face disfigurement, (e) higher job opportunities due to better voice and lesser physical deformity, and (f) reduction in spending on quacks and superstitious rituals that would not have any effect on cleft.

Adults can use cleft-afflicted children to garner sympathy and gain monetary benefits. For example, some may use abandoned children with cleft as beggars. Disability benefits in government and private sector may prompt some not to take any cleft remedies. Fear and fatalism are other reasons for no change in behaviour. In addition, absence of financial resources, time, and the tendency to avoid any effort at changing the status quo are other compelling reasons. Moreover, the target audience may also face prospects of very low accessibility to tertiary healthcare facilities required for comprehensive cleft care.

Other organizations worldwide that compete in the same space include Mission Smile, Transforming Faces, Re Surge International, and Smile Network International.

Positioning

Smile Train positions itself as a social marketer that provides free cleft surgery for poor patients. It funds poor newborn cleft children and adults for corrective surgery. In positioning itself as a funding provider, it needs to attract donors. However, raising awareness about cleft, screening and detection of cleft, and selecting deserving poor patients are also key activities of Smile Train.

It concentrates on (a) financial help for comprehensive cleft care so that cleft-afflictedintegrate into society well, (b) train Indian doctors on cleft care rather than employ foreign specialist doctors, and (c) use the local hospital infrastructure for screening, diagnosing, surgeries, and comprehensive cleft care.

Research

The major theories that underpin most efforts in social marketing are Theory of Reason Action/Planned Behaviour (Ajzen, 1991), Extended parallel processing (Witte, 1992), social learning (Ghazi et al., 2018), and diffusion of innovation. All these theories concentrate on three major actions, namely identification of motives of action, message strategies, and target audiences. In the case of Smile Train, these have been well understood in relating to the strategy that targets all stakeholders with different messages addressing each of their motives. The key Stakeholders are parents, partner hospitals and doctors, and donors. In addition, stage theories of behaviour change (Weinstein, Rothman, & Sutton, 1998) help explain howdifferent audiences react and thus define the segments.

Several studies have analyzed different aspects of cleft as a condition. In addition, Smile Train and its activities in India have also done studies. The published papers dealing with cleft are mostly in the medical area. These papers focus on the various descriptions of the medical condition and the related complications, diagnosis, and effectiveness of different interventions for treatment. The papers related to Smile Train and its activities in cleft care have, however, focused on the socio-economic dimensions of the problem. Moreover, the effect of different communication methods targeted at different members in the cleft ecosystem, i.e., patients, parents, etc.

Marketing Strategy

Product

Smile Train offers complete cleft care as a service for cleft patients (https://timesofindia.indiatimes.com/city/ahmedabad/Smile-Train-completes-10000-free- cleftsurgeries-in-Gujarat/articleshow/49335803.cms). It focuses on funding the poor for corrective surgery. It collaborates with doctors and hospitals to achieve its goal. Moreover, Smile Train helps in (a) spreading awareness about causes and detection of cleft, (b) removing superstitions surrounding cleft, and (c) helping educational institutions, employers, and public about cleft being a treatable condition.

Place

Globally, Smile Train has a presence in more than 100 countries. In India, it has a presence through its partner doctors and hospitals across more than 100 towns and cities. In addition, sharing of cleft correction success stories through media like radio, television, and Internet has helped in achieving greater reach. The Smile Train partnership provides an opportunity for the doctors, clinics, and hospitals to highlight indirectly their activities to the prospective clients. To ensure consistent and reliable surgical outcomes across locations, Smile Train facilitates surgeons and paramedical staff training with both volunteers and a virtual surgical simulator available online. In addition, a medical review board monitors the treatment quality. Another big contribution to the medical practitioners and researchers is that all the cleft patient data (identifier data masked) are available in the Smile Train database online forresearch and scrutiny.

Price

Smile Train seeks funding from donors to provide for a single cleft surgery. In addition, Smile Grants (http://www.livemint.com/Leisure/ yqIL1Q5hGXNob7lTkj940N/Freedom-to- smile-Satish-Kalra.html) ensure that poor cleft patient families receive money (a) to reach hospitals, (b) to compensate for lost work in treatment, and (c) children school fees. The cleft-afflicted families incur costs, when they decide to treat their children. These costs include the visit to a doctor, consultation, surgery, post-operative care, loss of wages due to care giving, and the cost of the child getting back to school. Thus, the huge costs associated with cleft are the price poor children and adults pay. In addition, psychological costs are high due to social embarrassment and religious beliefs.

Promotion

Smile Train uses several programs like Cleft Week and different media like Internet to raise cleft awareness and promote giving for cleft surgery. Cleft Week is a week dedicated to promoting doctor training on cleft and fun-filled activities for children at partner hospitals toraise cleft awareness. Smile Train uses partner doctors and hospitals to conduct cleft screening camps. It specifically targets schools for creating awareness that cleft is a treatable condition. It sensitizes normal school children to the ill-effects of socially ostracizing cleft- afflicted children. Smile Train uses days like the World Plastic Surgery day to create cleft awareness among doctors and the community.

It roped in a lip care marketer to create a special campaign of a cleft-affected girl getting over social ostracism after surgery. This multimedia (TV & Internet) campaign helped create greater cleft awareness among the public. Celebrities and ambassadors like Aishwarya Rai (https://www.mumbailive.com/en/bollywood/ aishwarya-rai-bachchan-announces-her-father- krishnaraj-rai-birthday-as-day-ofsmiles-supports-smile-train-india-17566), a popular Bollywood actor, in association with Smile Train, create greater cleft awareness.Internationally, Megan Mylan's 2009 Academy Award-winning documentary has helped raise awareness and funds for cleft corrective surgery for poor children. Smile Pinki (http://zeenews.india. com/sports/tennis/wimbledon-2013/smiling-pinki-flips-coin-at-wimbledon_ 764772.html) the documentary film dealt with an Indian girl's struggle with cleftand getting over it through surgery.

People

Smile Train has a small administrative setup managing the Indian operations. The key people, however, are the partner doctors and hospitals. They help in cleft corrective surgeries and pre- and post-operative care. Moreover, paramedical staff like audiologists and speech therapists also play a crucial role. Cleft care requires a team of medical and paramedical staff for successful treatment. Celebrities, volunteers, members of community organizations, and donors are people who facilitate cleft awareness through Smile Train.

Physical Evidence

In tertiary health care services, infrastructure plays an important role. A cleft surgery requires a team of specialist doctors and staff and a safe/hygienic environment. Since cleft surgery

affects ear, nose, and throat, sterile conditions need maintenance for effective surgery. Therefore, Smile Train selects partner hospitals based on an exhaustive survey.

Process

Smile Train helps cleft patients undergo surgery in partner hospitals. It has to process two different screenings simultaneously. The first screening is to identify financially needy cleftpatients. An economic background check ensures eligibility for corrective surgery funding. The second simultaneous screening is for the prospective doctors and hospitals. Smile Train needs to screen doctor, staff, and hospital infrastructure. In addition, funding organizations or individual donors need to be vetted before associating as partners.

Program Evaluation

Smile Train India has helped perform more than 475,000 surgeries in 170 partner hospitals through 300 surgeons across more than 100cities.This has been possible with onlyeight full- time employees on its rolls. Collaborations with CSR activities of large corporate (e.g., Bajaj Group), foundations (e.g., India Bulls Foundation), and charitable trusts (e.g., TATA Trusts) have helped it further its activities (https://yourstory. com/2016/10/the-smile-train/).Government is a contributor to betterment of its citizens' health. A key program metric is thesuccess in partnering with the Government of India. Several missions like National Health Missions and programs under these missions like Rashtriya Bal Kalyan Karyakram (National Child Welfare Program, http:// www.dailypioneer.com/state-editions/bhubaneswar/35k-kids- are-born-with-cleft-lippalate-a-year-in-india.html) have helped Smile Train in its social marketing efforts.

Discussion and Lessons Learned

Poor cleft patients face a serious challenge in getting over their health condition. They are unaware that it is a treatable condition and have constraints in accessing and affording corrective surgery. In view of this, they continue to suffer and face social ostracism due to their disfigured face. Smile Train India is a social marketing organization that targets awareness creation, screening and cleft detection, and funding of corrective cleft surgery. Smile Train achieves it through a unique design of partnership with doctors/hospitals and donors. It thus helps in social acceptance of cleft-affected, post-surgery, and contributes to developing healthy working individuals. Its networking model is helping the local community to gain and develop local expertise. Community involvement and local commitment help scale up and sustain efforts in social marketing. A social marketer as an enabler can spread asocial message faster than a controlling organization. Another lesson from SmileTrain'ssuccess is the power of demonstration (through success stories) in media. This has resulted in greater awareness of cleft as a treatable condition. Awareness leads to the breaking of superstitious beliefs.